Category Archives: DHS-7 Questionnaire

Did you know The DHS Program has made changes to the collection, calculation, and terminology used for maternal and pregnancy-related mortality data? Our new three-part video series based on our blog post addressing changes to the DHS-7 questionnaire breaks down everything you need to know.

The first video in the series, the Maternal Mortality Ratio (MMR) Indicator Snapshot, is our newest Indicator Snapshot. Based on the recently revised MMR definition, this video covers important things to know, why maternal mortality matters, calculation, where to find it in DHS reports, and how to use MMR in a sentence.

The second video details the differences between The DHS Program’s definitions of maternal and pregnancy-related mortality, as well as how our definitions compare to WHO’s definitions.

The DHS Program estimates of pregnancy-related mortality ratios (PRMR) have limitations which can make interpretation difficult. The final video in the series discusses how to interpret trends in PRMR, as well as other DHS survey indicators which may be more useful to program managers and policymakers.

You can find these videos and other resources on the Maternal Mortality page of our website. Did you find these video helpful? Need more guidance? Let us know in the comment section below!

As more countries look toward malaria elimination, the malaria landscape and its measurement are rapidly changing. The DHS Program has adapted its questionnaire and tabulation of malaria indicators to keep up with these changes, which are outlined below.

Indoor Residual Spraying (IRS)

In early 2017, IRS questions were dropped from the household questionnaire.

Why? IRS is typically very focal and done in a small number of districts. National household surveys are not typically sampled to provide representative estimates at this scale. Thus, measures of national IRS coverage from household surveys may not be meaningful.

In the 2016 Liberia MIS, knowing that 1% of households were sprayed in the 12 months before the survey does not tell users about the coverage of the intervention in target areas.

In the most recent questionnaire changes, The DHS Program dropped questions on retreatment of mosquito nets. As a result, tables on net ownership and use in the most recent tabulation plan only have one column for ITNs and do not include a separate column for LLINs. In other words, the ITN column represents nets that are treated with insecticide and no longer require retreatment. This definition is synonymous with LLIN.

Why? Bednets that require annual retreatment and the products used for retreatment are no longer distributed, so the distinction between ITNs and LLINs is no longer meaningful. Differences between values in the LLIN and ITN columns in current ITN tables are minor and likely due to misclassification.

Implications: When looking at trends involving bednets, The DHS Program recommends comparing data from the ITN column over time rather than mixing and matching with the LLIN column from older surveys. Just keep in mind that the definition of ITNs in surveys released before 2018 included nets that had been retreated.

Intermittent preventive treatment during pregnancy (IPTp)

In the past, the table on “Use of IPTp by women during pregnancy” specified that the source of at least one of the doses of SP/Fansidar was an antenatal care visit. Moving forward, the source of IPTp is no longer specified. The question regarding the source of SP/Fansidar will remain in the questionnaire, but it will no longer be presented as part of the standard indicator.

Why? The original language specifying the source of doses was added when IPTp was a new intervention and there was concern that women might report medication taken for treatment of malaria instead of malaria prevention. The intervention is now well known, and this specification is no longer necessary.

Implications: Users should use caution when interpreting trends if the data are pulled directly from the table in the final report. However, the indicator measuring doses of SP/Fansidar regardless of the source can be calculated for past surveys in the datasets and is available in STATcompiler.

This is Part 3 in the DHS-7 questionnaire blog series that explores the new data that are available in DHS reports resulting from changes made to the DHS questionnaires in 2014. This week’s post focuses on changes made to gather additional information about DHS respondents.

Part 3: Respondents’ Characteristics

Understanding DHS survey respondents is critical to interpreting DHS data. In addition to fertility and health data, the DHS captures information on education and literacy; exposure to mass media; ownership of goods, homes, and land; employment; and use of tobacco. Some of these topics are tabulated in Chapter 3 on Respondent Characteristics, while others are discussed in the chapter on Women’s Empowerment. Changes to these topics are outlined below.

More precise collection of literacy data. In previous DHS surveys, women and men who had attended at least some secondary education were assumed to be literate and only those with primary education and below were asked to read a card in their local language to test for literacy. In DHS-7, only those who have gone to “higher than secondary school” are assumed to be literate; all others, including those who have attended or completed secondary school, are asked to read the literacy card (pictured right).

Why? This change was made to improve the precision of literacy measures. Not all people who have attended some secondary school are literate. In some cases, this confirmation of literacy may also point to a misclassification of educational levels of respondents.

Implications: In some countries, this change may affect the interpretation of trends, as a more inclusive group of respondents is actually being tested for literacy in DHS-7 surveys. Recently released surveys do not suggest a major impact, however. In the 2015-16 Malawi DHS, for example, 72% of women were found to be literate (when women with primary, secondary, or secondary completed were asked to read the card). This includes about 40 female respondents (out of over 24,000) with some secondary education who previously would have been assumed to be literate but were identified in the 2015-16 survey as illiterate because they could not read the card. This more precise measure adjusts the national literacy rate in Malawi by only 0.15%; both methodologies result in a 72% literacy rate at the national level.

Additional questions on mobile phone ownership. Previous DHS surveys collected data on mobile phone ownership at the household level. In DHS-7, women and men are asked about mobile phone ownership individually. These data are presented in the Women’s Empowerment chapter.

Why? Having one mobile phone per household is not very informative when programs are designing mobile interventions to reach pregnant women or facilitate receiving HIV results.

New finance-related questions. In DHS-7, women and men are now asked whether or not they have used their mobile phone for financial transactions, and whether or not they have an account in a bank or other financial institute. These data are tabulated in the Women’s Empowerment chapter.

New question on internet usage.Respondents to woman’s and man’s questionnaires are now asked if they have ever used the internet. Those who answer yes are asked if they’ve used the internet in the past 12 months. For those who have used the internet in the year before the survey, they are also asked, “during the last month, how often did you use the internet?”New question on ownership of title or deed for house or land. Previously, women and men were asked if they owned a house or land alone or jointly. Now they are asked two follow-up questions if they say yes to the ownership questions: whether or not they have a title deed, and whether or not their name is on the title deed. These data are tabulated in the Women’s Empowerment chapter. Because these questions may be considered sensitive not all countries will elect to include them in their surveys.

New and more detailed questions on tobacco use. In DHS-7, women and men are asked more detailed questions about tobacco use to capture how often the respondent smokes or uses other tobacco products. Men are also asked whether they have previously been a daily smoker, how many of different types of tobacco products are used per day and per week, and whether or not the man uses smokeless tobacco.

This is Part 2 in the New Data Available from DHS-7 Questionnaire blog series that explores the new data that are available in DHS reports resulting from changes made to the DHS-7 questionnaire in 2014. This post focuses on changes made to improve the quality and quantity of data collected about water and sanitation.

Bottled water is now defined as an improved or unimproved source of drinking water depending on the source of water for cooking and handwashing. In the previous DHS-6 questionnaire, if a household indicated that the main source of drinking water for household members was bottled water, this was categorized as an improved source of drinking water. In the DHS-7 questionnaire (as in DHS-5), a household that uses bottled water for drinking is asked a follow-up question about the source of water used for cooking and handwashing (see questionnaire). For example, a household that uses bottled water for drinking but surface water (an unimproved source) for cooking and handwashing is considered to have an unimproved source. A household that uses bottled water for drinking and piped water (an improved source) for cooking and handwashing is considered to have an improved source. Both categories are listed in Table 2.1 (see figure).

Implications: For most countries, this change will simply add insight into how households use water sources for different purposes. In countries where there is heavy reliance on bottled drinking water, reclassification of some of the bottled water users as having an unimproved water source may affect interpretation of trends in the larger “improved source” and “unimproved source” categories between surveys that include information about the source of water for cooking and handwashing and those that do not.

New category of improved source of drinking water added. Respondents to the household questionnaire can now indicate that their drinking water source is water piped to a neighbor.

Why? This response category was added because it is a common source of drinking water in some countries.

New question and table on availability of water. For households using piped water or water from a borehole or tubewell, a new question has been added asking if water was available without an interruption of at least one day in the past 2 weeks (see Table 2. 2).

Why? Scheduled or unscheduled interruptions in the water supply may force households to use unimproved sources. All persons should have sustainable access to adequate quantities of affordable and safe water. The new question helps determine whether or not households have a sustainable supply of water.

Implications: Water availability from some improved sources, such as piped water or tubewells, is not always consistent. Intermittent and unreliable water services result in inconvenience to water users and increased risk of compromised water safety.

Sanitation and toilet facilities language clarified. The collection of data about toilet facilities has changed only marginally, however the language used to describe the different types of unimproved sanitation has been clarified. In DHS-7 reports, sanitation is divided into the categories seen in Table 2.3 from the 2015-16 Malawi DHS. Improved sanitation includes flush/pour systems, VIP latrines, and composting toilets, among others. Unimproved sanitation now includes three subcategories: a shared facility (this may still be a flush system, but by definition a shared facility is not improved); an unimproved facility, such as a pit latrine without a slab, an open pit latrine or a bucket; and open defecation, that is, the household has no facility and uses the field or bush.

Why? Improved sanitation facilities are meant to separate human excreta from human contact. If an otherwise improved sanitation facility is shared with other households, the likelihood of exposure to fecal materials is increased.

Implications: In this case, the labeling of these categories is all that has changed. The DHS STATcompiler has been updated with new labels to reflect these categories. Interpretation of data for trend analysis is not affected.

New question added on location of toilet facilities. The DHS-7 questionnaire now also asks where the toilet facility is located. Table 2.3 categorizes these locations as “in own dwelling,” “in own yard/plot,” and “elsewhere.”

Why? If the sanitation facility used by the household is not in the dwelling or yard/plot, it is more difficult to access when needed, and it may pose a safety issue, especially for women and children.

Implications of this addition are not yet known; analysis of future survey data may provide insight.

Mobile sites for handwashing now captured. In previous surveys, interviewers asked household respondents to show them where members of the household usually wash their hands. The DHS-7 questionnaire allows for interviewers to indicate whether this handwashing site was fixed (such as a sink) or mobile (such as a pitcher or basin) (see Table 2.7 from the 2015-16 Malawi DHS).

Why? Many households without piped water do not have a fixed place for handwashing. In some countries (particularly in Africa), many households rely on mobile items for handwashing. When hands need to be washed, the individual may move a jug, basin, and soap from inside the home to the outdoor courtyard in order to wash hands. The ability to determine whether handwashing relies on a fixed or mobile place helps to interpret the handwashing data and to understand the physical and social norm-related barriers to handwashing with soap.

Implications: Early review of data from DHS-7 countries suggest that adding the mobile site for handwashing increases the percentage of households that will report that they have a handwashing site. Trends in this area should be interpreted with caution, as an increase in reported handwashing sites may be a function of the questionnaire change rather than a true change in handwashing practices.

In 2014, The DHS Program began the process of updating the standard DHS questionnaires. With input from stakeholders, feedback from in-country implementing agencies, and a host of lessons learned from the previous 5-year program, we added, modified, and, in some cases, deleted questions. For many indicators, the actual questionnaire did not require an adjustment, but the calculation of indicators or the tabulation of the data needed an update to reflect new international indicators and best practices.

While questionnaire revision started in 2014, it can take a long time to see this exercise bear fruit. The 2015-16 Malawi DHS, for example, went into the field with the DHS-7 updated questionnaires in October 2015. The final report and dataset for the 2015-16 Malawi DHS were released in March 2017, allowing us to explore the new data for the first time.

In this blog series, New Data Available from DHS-7 Questionnaire, we will be detailing, topic by topic, some of the key changes to the questionnaire, with a focus on why the changes were made, how the changes affect the tabulations, and some guidance on how the resulting data should be interpreted.

Part 1: Maternal and Pregnancy-Related Mortality

DHS surveys now collect data to provide the maternal mortality ratio in line with the definition provided by WHO. For almost 30 years, The DHS Program has collected data on maternal mortality in a subset of countries. In previous DHS cycles, maternal mortality was defined as any death to a woman while pregnant, during childbirth, or within two months of delivery. The WHO definition of maternal mortality is more precise: any death to a woman during pregnancy, childbirth, or within 42 days of delivery but not from accidental or incidental causes (see full WHO definition here). The new DHS-7 questionnaire allows us to calculate the maternal mortality ratio (MMR) in closer alignment with this more precise WHO definition.

As always, women interviewed in the DHS are asked to list their siblings. The interviewer then collects information about the siblings’ survival status. In the case of female siblings who have died at age 12 or older, the interviewer inquires whether or not the sister died during pregnancy, childbirth, or within the 2 months following delivery. If the sister died within 2 months after childbirth, the interviewer asks how many days after childbirth the sister died. This clarification on the number of days is a new addition to the DHS-7 questionnaire. The interviewer then asks additional questions to determine if the death was accidental or due to violence. In DHS-7 these deaths are excluded from the calculation of the MMR per the WHO definition.

Why? These changes were made to improve the precision of the MMR, as well as to align the DHS estimation of the MMR with the standard definition provided by the WHO.

Implications: While the newly added questions allow for a more precise and up-to-date measure of maternal mortality, the change does present challenges for interpretation. DHS has reported on maternal mortality for 30 years, but estimates obtained using the new definition of maternal mortality cannot be directly compared to the old definition of maternal mortality which included deaths up to 2 months after delivery and did not exclude deaths due to accidents and violence.

And yet, one of the main objectives for conducting DHS surveys is to provide trend data. Fortunately, the old definition of maternal mortality can still be applied to calculate the mortality ratio estimate comparable to estimates from previously collected mortality data. This less precise measure of mortality is referred to as the pregnancy-related mortality ratio (PRMR).

DHS reports that include the maternal mortality module will now contain both the maternal mortality ratio and the pregnancy-related mortality ratio. The maternal mortality ratio will be used as the primary point estimate, but the pregnancy-related mortality ratio will be shown in an additional table and in figures to illustrate the trend. Keep in mind that the new measure of maternal mortality, by definition, will result in a lower maternal mortality ratio than the old measure because the accidental and violence-related deaths to women during the maternal period and deaths occurring between 42 days and 2 months after childbirth are being excluded from maternal deaths while using the new definition but included while using the old definition.

Summary of Maternal Mortality and Pregnancy-related Mortality:

Maternal Mortality Ratio

The number of maternal deaths to any woman during pregnancy, childbirth, or within 42 days of delivery excluding accidents and acts of violence per 100,000 live births

More precise

Not comparable to surveys before DHS-7

Pregnancy-related Mortality Ratio

The number of pregnancy-related deaths (deaths to a woman during pregnancy or delivery or within 2 months of the termination of a pregnancy, from any cause, including accidents or violence per 100,000 live births

Less precise

Comparable to previous surveys; shown to allow for trend interpretation

The DHS-7 questionnaire includes additional prompts to fully capture more siblings and siblings’ deaths. In previous DHS questionnaires, women were asked to list their siblings in order and then were asked follow-up questions about their survival status. In the DHS-7 adult mortality module, respondents are asked to list their siblings without worrying about their order but are then asked a list of probing questions to ensure that all siblings have actually been recorded. This change is likely to produce a more complete list of siblings for which information on adult and maternal mortality is collected. Once a complete list is produced they are then ordered and the questions on their survival status and age or age at death and years since death, as well as the maternal mortality related questions, are then asked as applicable.

Why? Several studies have suggested that respondents’ lists of siblings are not always complete. This often happens when the sibling is a half-brother or sister, when the sibling did not live with the respondent as a child, or when the sibling has died. A pre-test in Ghana indicated that the addition of these probing questions resulted in capturing additional siblings for about 10% of women.

Implications: Omissions in the sibling history can affect the adult and maternal mortality ratios in different ways. The inclusion of more siblings tends to increase the adult mortality rate. This is because often the siblings who were previously omitted were not spontaneously mentioned because they have already died. However, studies suggest that these deaths are not disproportionately maternal deaths, so a more complete sibling listing might result in a lower maternal mortality ratio.

Key Take-Aways

The changes described above may sound confusing for non-demographers. The major points to remember for DHS data users include:

The new Maternal Mortality Ratio is not comparable with previous measures of maternal mortality in DHS surveys

For trends, look at Pregnancy-related Mortality Ratio

Despite the different names, both measures include deaths during pregnancy. The MMR is a more precise measure as it excludes some of the deaths during pregnancy that were not related to pregnancy (i.e. accidents and acts of violence).

Maternal mortality is still a relatively rare event, and therefore both MMR and PRMR have wide confidence intervals. Both measures are always presented with their confidence interval so that the user can draw their own conclusions about the relative certainty of the point estimate.

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